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r <br /> SERVICE REQUEST r <br /> Business or Property FACILRY IDM SERVICER00 <br /> JYMERI OPERATOR .-��//,,�I//JJ�` CJ BILLING PARTY 0 <br /> FACIJTY NAME <br /> SREADDRESS <br /> i_I l `�Sbr.l NuMr WeNan C{rl_A.S� yqM M.nrJ Tmr Suer/ <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE zAAYMENT <br /> RECEIVE <br /> PHONE Mi APNM LAND USE APPLICATIONM <br /> f ) FEB 1 5 2001 <br /> PHONE M2 m. SOSDtSTTucT SAWJJLIA`JUIM 0UNTY <br /> PUBLIC I <br /> CONTRACTOR I SERVICE REOUESTOR ENV1HVNMLNIAj HEALIHUIVISION <br /> REQUESTOR r BILLING PARTY 0 <br /> vy, <br /> BUSINESS NAME PHONE M �• <br /> MAILING ADDRESS FAX M <br /> Po ►3 ow o <br /> CITY yf <br /> G STATE LP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acJm""c that an site andlor pmied specific <br /> PUDUC HEALTH SETNICES E1NVR0HMEHTAI HEALTH DMSIOH hourly charges=ocialed with this project or activity will be billed to me or my business asidentified on this form. <br /> I also certify that I have prepared this application and that the"k to be performed rail be done in accordance with all SAN JOAOUM COl1NTY Ordin rico Codes,Standards,STATE and <br /> FEDERAL Iavrs. n F <br /> APPl1CANT SIGNATURE: <br /> PROPERTY I BUSINESS OWNER O OPERATOR I MANAGER 0 On1ERAummzEDACENT 0 <br /> IArvs ewris nef lb llsLGPum ryno/efauNorlraUon to slln is npukvd iiN/e <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property holed at the above site address,hereby authorize the rNease of <br /> any and all results,geolechnial data andlor environmentalfsila assessment Information to the SAN JOAOJw Counry Public HEALTH SERVICES ENmciNMENTAL HEALTH DNcrotN as soon <br /> as It Is available and at the same Eme It is provided to me or my representative. <br /> rSERIMIK.ETED: C _ i` � / -�„,l���"tk�rr,�,o°� �,,-Ah \ Z <br /> s 6Z <br /> The r ;�/ h 9t,4� 4- L4 <br /> y <br /> rt e, <br /> Inc L i2 Szo s�J Gi r/` <br /> - <br /> INSPECTOR'S$IGNATURE d' ,—PL COINRACTOR S SIGNANRE[ / LL” ZX 1 a <br /> APPROVED BY: EMPLOYE'_M: -v C DATE: z C a <br /> ASSIGNED TO: �T EMPLOYEE k: I DATE: J <br /> Date Service Completed (ifalrcadyeompided): SERVICECODE: .PIE: �Z <br /> 516 I/ <br /> Fee Amount Amount Paid /) U Payment Dale <br /> Payment Type Invoice M' Checked �� Received y: <br />